Improved Patient Care Utilizing
Wrap-Around Services:
Selected diagnosis of Asthma and
Stress Management
Saara Schwartz, MD
Mariela Gabaroni, MS, MCHES
Objectives
Define Wrap Around services
 Recommendations for the treatment of
Asthma and Stress Management
 Discuss a minimum of 3 benefits of
utilizing wrap-around services
 Discuss the use of technology to assist in
patient education efforts and provide a
holistic experience

What are Wrap-Around Services?
In recent years, wrap-around has been
most commonly conceived of as an
intensive, individualized care planning
and management process
 It is a holistic way of engaging individuals
with specific needs

Why Wrap-around services?
Today’s environment stresses

◦
“ Do More with Less”
How is this affecting care

◦
◦
◦
less time with patients
education is abbreviated
Scenario…
My Magic Wand
Today patients want to get better
quickly.

◦
There is no time to be sick. So they
all request to be given a wonder drug.
However, if only given a
medication…

◦
◦
Results will only be short-term
but will it help sustain continued
health?
How do we help patients
maintain health?
Who is part of the team?
Patient
 Clinicians
 Health Educators
 Pharmacy staff
 Acupuncturist
 Massage Therapist
 Nutritionist
 Counseling

Services Model
CLINICAL
SERVICES
COUNSELING
SERVICES
RECREATIONAL
SERVICES
SOCIAL
SERVICES
Patient
PHARMACY
SERVICES
HEALTH
EDUCATION
SERVICES
NUTRITION
SERVICES
COMPLEMENTARY
ALTERNATIVE
THERAPY
SERVICES
Wrap-Around Program
Framework






Comprehensive array of services
Coordination of services
Cultural competence
Early identification and interventions
Strength-based individualized service
planning
Accountability through outcome evaluation
Wrap-Around Concept is…
A framework and guide, not a
prescription
 Flexible and creative
 Adaptive to patient needs
 Consistent in philosophy

Wrap-Around Services at
Florida International
University
Student Health Services
Diagnoses Selected
◦ Diagnostic Data
 Asthma
 Increased incidence rate from July 2011 through May 2013
◦ NCHA data
 Stress
 Fall 2012 National Data- 19.6%
 Fall 2012 FIU Data- 24.5%
Asthma
The prevalence in a student population is
3.68% with a mildly growing trend
 Females>Males
 Smoking is common among students with
Asthma

Classifying Asthma Severity
Classification of asthma severity ≥ 12 years of age*
Components of severity
Impairment
Intermittent
Persistent-mild
Persistent-moderate
Persistent-severe
Symptoms
≤ 2 days per week
> 2 days per week, but not
Daily
Throughout the day
> Once per week, but not
Often 7 times per week
daily
Nighttime awakenings
≤ 2 times per month
3 to 4 times per month
nightly
Short-acting beta agonist
≤ 2 days per week
> 2 days per week, but not
Daily
Several times per day
Minor limitation
Some limitation
Extremely limited
Normal FEV between
FEV ≥ 80 percent of
FEV > 60 percent but < 80
FEV < 60 percent of
exacerbations; FEV >80
predicted; FEV /FVC normal
percent of predicted;
predicted; FEV /FVC reduced
FEV /FVC reduced 5 percent
>5 percent
≥ 2 per year†
≥ 2 per year†
use for symptom control
more than once per day
(not for prevention of
exercise-induced
bronchospasm)
Interference with normal
None
activity
Lung function
1
1
1
1
percent of predicted;
1
1
1
1
FEV /FVC normal
1
Risk
Exacerbations requiring
0 to 1 per year†
≥ 2 per year†
oral systemic
Consider severity and interval since last exacerbation; frequency and severity may fluctuate over time for patients in any
corticosteroids
severity category; relative annual risk of exacerbations may be related to FEV
1
Medications

Rescue Medications:
◦ Albuterol
◦ Xopenex
◦ Antihistamine

Maintenance Medications:
◦ Inhaled Corticosteroids
◦ Leukotrines
◦ Corticosteroids with long acting Beta agonist
Why Treat?
Asthma should not complicate or
cause missed days of school.
Asthma control, therefore, is a must so
that this period in a student’s life will
be filled with academic successes and
not failures.
Challenges to the College Student
With Asthma
This may be the first time student is away
from home (need to take on the task of
being independent)
 Perceived attitudes “I am invincible”
 Increase risk for illness:

◦ Dorms
◦ Roommates
◦ Sorority / Fraternity
Challenges to the College Student
With Asthma
Unable to determine the severity of their
Asthma
 Worsening of Symptoms at College
 Uninsured
 Perceived cost vs. Perceived gain
 Transportation
 Identifying Resources

Education


Provision of asthma education is
associated with decreased hospitalizations
and emergency department visits for
patients with asthma. Asthma education is
underused by primary care physicians and
rates have declined from 2001-2006.
Interventions designed to promote
awareness and greater use of asthma
education is needed.
(reference: Decreasing frequency of asthma education in primary care. - Hersh AL - J Asthma - 01-FEB-2010; 47(1): 21-5)
Asthma Wrap-Around Services
Clinical visit
 Referral
 Pre-test
 Education sessions

◦ Individual
◦ Classroom
Post-test
 Follow-ups
 Evaluation

Asthma Education Sessions
STRESS

NCHA Data
◦ Stress is the number one impediment to
academic success
◦ Anxiety is a close second impediment to
academic success
◦ Why?
Millennial Generation
Household income is higher, driven in large part
by the fact that both parents are working.
 Positive social habits- teamwork, achievement,
modesty, and good conduct
 Negative attributes- being over scheduled,
heavily monitored, and pressured to excel
academically
 They have witnessed in real time the horrible,
man-made tragedies and natural disasters in a
way that no other generation has experienced
via television and Internet

The Millennium Student
Special
 Sheltered
 Confident
 Team-oriented
 Achieving
 Pressured
 Conventional

College Stress:
The college years have been considered
one of the most stressful times in a
person's life as well (Hales, 2009 )
 College students are expected to carry a
more difficult workload at a faster pace
while adjusting to a new environment
with little or no supervision (Missouri AHEAD,

2007).
College Stresses:
New social situations
 Loss of supervision
 Searching for themselves
 Need to learn coping strategies
 Lack of sleep

◦ New York Times Article
http://www.nytimes.com/2013/04/28/opinion/sunday/diagnosing-the-wrongdeficit.html?pagewanted=3&src=me&_r=0
◦ Huffington Post Article
Quick fixes

Substance Abuse
◦
◦
◦
◦
Marijuana
Alcohol Abuse
Increased Tobacco Use
Performance enhancing drugs
Suicide
 Prescription Medication

Melatonin
Melatonin is a hormone made by the
pineal gland
 Melatonin helps control your sleep and
wake cycles
 Very small amounts of it are found in
foods such as meats, grains, fruits, and
vegetables
 Light affects how much melatonin your
body produces ( seasonal affective
disorder)

Side Effects of Melatonin
Sleepiness.
 Lower body temperature.
 Vivid dreams.
 Morning grogginess.
 Small changes in blood pressure.
 Cognitive dysfunction

Benzodiazepines
Benzodiazepines are the anxiolytics of
choice in the acute management of
generalized anxiety
 Alprazolam 0.25-0.5mg; Lorazepam1-2mg or
clonazopam 1-2mg are all controlled drugs,
need an MD prescription, and are potentially
dangerous because of dependency issues and
the potential for overdosing.
 The most common side effects for
benzodiazepines are drowsiness and
dizziness.

SSRIs
SSRIs or SNRI’s are the first-line
medications for sustained treatment of
generalized anxiety disorders, panic
disorders, depression.
 Expect a 2-4 week delay before these
drugs begin to take effect.
 Side Effects include insomnia, rashes,
headaches, joint and muscle pain, stomach
upset, nausea, or diarrhea. These problems
are usually temporary, mild, or both.

SSRI Side Effects
Bleeding problems-reduced blood clotting capacity
that increases risk for stomach or uterine bleeding. If
patients use SSRIs and NSAIDs (aspirin, ibuprofen,
naproxen, COX-2 inhibitors) at the same time, the
risk more than doubles, so these drugs must be
combined with care.
 Diminish sexual interest, desire, performance,
satisfaction, or all four. - Lowering the dose, switching
antidepressants, or, for men, taking a drug like
sildenafil (Viagra) can help.
 Suicide- When compared with a placebo, all
antidepressants, including SSRIs, seem to double the
risk of suicidal thinking, from 1%–2% to 2%–4%, in
both children and adults

Buspirone HCl
Buspirone HCl 15-60mg usually given in
three divided doses daily.
 Side effects are common, benefits are not
seen for weeks; however there are no
dependency issues with this class of drugs.
 Possible side effects from Buspar are
dizziness, headaches, nausea, nervousness,
lightheadedness, excitement, and trouble
sleeping.

Beta Blockers
Beta blockers control some of the physical
symptoms of anxiety, such as trembling and
sweating.
 Clinicians can prescribe Propranolol 10-20mg
30mins before performance for performance
anxiety.
 Common side effects from betablockers include
fatigue, cold hands, dizziness, and weakness.
 In addition, betablockers generally are not
recommended for people with asthma or
diabetes because they may worsen symptoms.

Stress Management Wrap-Around
Clinical
Appointment
Refer to
counseling
Refer to
Wellness
Stress Management Program
Massage Therapy
 Meditation
 Aromatherapy
 Acupuncture
 Stress Management Consultations
 Time Management
 Yoga
 Evaluation

What coping mechanisms do
college-aged Millennials employ?
Listening to music
 Sleeping
 Social interactions
 Relaxing
 Surfing the internet
 Calling parent
 Prayer

Benefits to the patients
More individualized care
 Exposure to alternative therapies in a safe
and economical environment
 Better understanding of the diagnoses and
possible implications
 Helps patient sustain optimal health

Benefits to Student Health
Operations
Maximize clinician time
 Better engagement with patients
 Collaboration of care
 Creates a positive environment for
holistic care

Enhancing Wrap-Around through
the use of Technology
Online tutorials
 Tweets
 Smart apps
 Secure messaging
 YouTube videos

Questions?
Saara Schwartz, MD
Medical Director
Mariela Gabaroni, MCHES
Associate Director
Florida International University
Student Health Services
Florida International University
Student Health Services
Email: schwarts@fiu.edu
Phone: 305-348-5960
Email: xgabaron@fiu.edu
Phone: 305-348-4020